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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Blunt chest trauma is a rare cause of acquired benign airway stenosis&#46; Only 0&#46;4&#8211;1&#46;5&#37; of these events induce airway injury&#44; which mostly occurs in the right main bronchus and within 2<span class="elsevierStyleHsp" style=""></span>cm of the tracheal carina&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> Half of all airway injuries are not identified during the first 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h&#44; because normal ventilation may be present despite the airway injury and because of non-specific symptoms and other injuries&#44; such as head trauma&#44; abdominal injuries&#44; and multiple extremity fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> If airway injuries are not recognized early&#44; an aberrant airway healing process can lead to the formation of granulation tissue and collagen deposition and&#44; ultimately&#44; to delayed tracheobronchial stenosis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Although delayed tracheobronchial stenosis after blunt chest trauma is treated with bronchoscopic intervention &#40;e&#46;g&#46;&#44; balloon dilation&#44; laser ablation&#44; and airway stents&#41;&#44; surgical intervention&#44; or a combination of these methods&#44; no treatment consensus or guidelines have been established for this condition&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2&#44;3</span></a> The management of delayed tracheobronchial stenosis caused by blunt chest trauma highly depends on patient status&#44; severity of symptoms&#44; location and extent of stenosis&#44; degree of distal pulmonary parenchymal destruction&#44; and local expertise&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Here&#44; we describe the case of a patient with delayed right main bronchus stenosis involving the tracheal carina after blunt chest trauma who was successfully treated with tracheobronchial anastomosis&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 34-year old male current smoker had been involved in a motor vehicle accident at the age of 21&#46; He suffered bilateral pneumothorax&#44; which was treated only with chest drainage tubes&#46; The patient developed pneumonia every 12 years starting at the age of 24&#46; During the pneumonia episodes&#44; he complained of wheezing and dyspnea&#46; The patient did not have any lower respiratory tract infections during childhood&#46; Recently&#44; he started having recurrent obstructive pneumonia every 12 months&#44; which led him to visit the Department of Respiratory Medicine of the local hospital&#46; Chest computed tomography &#40;CT&#41; showed ground grass opacity and consolidation in the right middle and lower lobes&#44; and bronchial mucous retention with stenosis of the right main bronchus&#44; the length of which was less than 1<span class="elsevierStyleHsp" style=""></span>cm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#44; B&#41;&#46; Flexible fiber-optic bronchoscopy &#40;FOB&#41; showed a fibrotic lesion causing almost complete stenosis of the proximal right main bronchus&#44; with the exception of a pinhole located at the lateral posterior aspect of the stenosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; His forced vital capacity &#40;FVC&#41;&#44; forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s &#40;FEV<span class="elsevierStyleInf">1</span>&#41;&#44; FEV<span class="elsevierStyleInf">1</span>&#47;FVC ratio&#44; expiratory reserve volume &#40;ERV&#41;&#44; and residual volume &#40;RV&#41;&#47;total lung capacity &#40;TLC&#41; ratio&#44; were 92&#46;4&#37; &#40;4&#46;23<span class="elsevierStyleHsp" style=""></span>L&#41;&#44; 61&#46;4&#37; &#40;2&#46;47<span class="elsevierStyleHsp" style=""></span>L&#41;&#44; 58&#46;39&#37;&#44; 76&#46;8&#37; &#40;1&#46;29<span class="elsevierStyleHsp" style=""></span>L&#41;&#44; and 32&#46;13&#37;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>F&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was referred to our hospital for treatment of the right main bronchus stenosis&#46; We selected surgical intervention &#40;supplemental video&#41;&#46; Under general single-lung ventilation with a double-lumen tube&#44; we performed a right posterolateral thoracotomy and found that the lung had adhered to the chest wall and that the middle and lower lobes showed consolidation&#46; We opened the right main bronchus at the proximal side&#59; however&#44; the stenosis remained&#44; and we resected half of the tracheal carina and the lower part of the trachea&#46; At the distal side&#44; the main bronchus was removed to the smallest extent possible&#44; which was approximately 2<span class="elsevierStyleHsp" style=""></span>cm&#46; Anastomosis was performed with continuous suture for the mediastinal side and interrupted suture for the other part using 4-0 polydioxanone suture&#44; and pedicled pericardial fat tissue was used as a cover&#46; The patient was discharged on postoperative day 12 without any postoperative complications&#46; Pathological analysis of the resected specimen showed the presence of granulation tissue with a focal fibrosis lesion and no evidence of malignancy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Follow-up chest CT &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41; and flexible FOB &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E&#41; performed 3 months postoperatively showed successful healing of the anastomosis with luminal patency&#46; A follow-up pulmonary function test revealed improvement of the obstructive ventilatory defect based on FVC&#44; FEV<span class="elsevierStyleInf">1</span>&#44; FEV<span class="elsevierStyleInf">1</span>&#47;FVC ratio&#44; ERV&#44; and RV&#47;TLC ratio values of 101&#46;3&#37; &#40;4&#46;66<span class="elsevierStyleHsp" style=""></span>L&#41;&#44; 93&#46;3&#37; &#40;3&#46;77<span class="elsevierStyleHsp" style=""></span>L&#41;&#44; 80&#46;9&#37;&#44; 98&#46;8&#37; &#40;1&#46;67<span class="elsevierStyleHsp" style=""></span>L&#41;&#44; and 27&#46;6&#37;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>G&#41;&#46; The patient did not develop pneumonia for 10 months after the operation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">If stenosis involves the tracheal carina&#44; surgical intervention may be associated with an increased risk because of technical difficulties and a high level of postoperative complications&#44; such as anastomotic dehiscence and restenosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4&#44;5</span></a> Two previous studies showed that delayed airway stenosis with involvement of the tracheal carina after blunt chest trauma was successfully treated with repeated balloon dilation and stent placement&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6&#44;7</span></a> Thus&#44; it was considered that we should perform a bronchoscopic intervention&#59; however&#44; we decided on surgical intervention for the following reasons&#46; First&#44; we considered that we could perform tension-free anastomosis&#44; because the stenotic lesion affected the main bronchus exclusively&#46; Second&#44; the stenosis did not induce the formation of a right lung abscess&#46; Third&#44; bronchoscopic treatments might require repeated interventions because of migration and formation of granulation and because of the recurrence of stenosis after stent removal&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Forth&#44; the patient was young and his preoperative condition was good&#46; In the present case&#44; surgical intervention was an acceptable method for managing stenosis involving the carina&#46; Previous studies reported no perioperative mortality by surgical intervention for benign airway stenosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">9&#44;10</span></a> Therefore&#44; surgical intervention should be considered in the future under the same condition&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The median time from initial injury to diagnosis of delayed tracheobronchial stenosis is 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Kiser et al&#46; reported an absence of association between time to the diagnosis of delayed tracheobronchial stenosis and the rate of successful surgical repair&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> Perioperative complications related to surgical intervention for tracheobronchial stenosis includes empyema&#44; rebleeding&#44; stenosis&#44; and fistula&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2&#44;12</span></a> The current patient was diagnosed 13 years after the initial motor vehicle accident and experienced no perioperative complications&#46; The long-term complications or long-term follow-up outcomes are unknown<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a>&#59; therefore&#44; we should carefully investigate the future disease profiles of this case&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Here&#44; we successfully treated a case of delayed airway stenosis involving the tracheal carina with surgical intervention&#46; As the treatment consensus or guidelines for delayed airway stenosis after blunt chest trauma have not been established&#44; a very careful clinical and radiological evaluation is needed to prevent peri- and post-operative complications before deciding on whether to adapt this technique&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial conflicts</span><p id="par0040" class="elsevierStylePara elsevierViewall">This study was funded in part by the JSPS KAKENHI 19K17634 &#40;SH&#41;&#46; The Department of Advanced Medicine for Respiratory Failure is a Department of Collaborative Research Laboratory funded by Teijin Pharma&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">Satoshi Hamada reports grants from Teijin Pharma&#44; outside the submitted work&#46;</p></span></span>"
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Scientific Letter
Delayed Right Main Bronchus Stenosis With Involvement of the Tracheal Carina After Blunt Chest Trauma: Successful Treatment With Tracheobronchial Anastomosis
Satoshi Hamadaa,b,
Corresponding author
sh1124@kuhp.kyoto-u.ac.jp

Corresponding author.
, Akihiro Ohsumic, Tatsuya Gotoc, Masatsugu Hamajic, Hiroshi Datec, Toyohiro Hiraid
a Department of Advanced Medicine for Respiratory Failure, Graduate School of Medicine, Kyoto University, Kyoto, Japan
b Department of Respiratory Medicine, Ayabe City Hospital, Kyoto, Japan
c Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
d Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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    "titulo" => "Delayed Right Main Bronchus Stenosis With Involvement of the Tracheal Carina After Blunt Chest Trauma&#58; Successful Treatment With Tracheobronchial Anastomosis"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Blunt chest trauma is a rare cause of acquired benign airway stenosis&#46; Only 0&#46;4&#8211;1&#46;5&#37; of these events induce airway injury&#44; which mostly occurs in the right main bronchus and within 2<span class="elsevierStyleHsp" style=""></span>cm of the tracheal carina&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> Half of all airway injuries are not identified during the first 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h&#44; because normal ventilation may be present despite the airway injury and because of non-specific symptoms and other injuries&#44; such as head trauma&#44; abdominal injuries&#44; and multiple extremity fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> If airway injuries are not recognized early&#44; an aberrant airway healing process can lead to the formation of granulation tissue and collagen deposition and&#44; ultimately&#44; to delayed tracheobronchial stenosis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Although delayed tracheobronchial stenosis after blunt chest trauma is treated with bronchoscopic intervention &#40;e&#46;g&#46;&#44; balloon dilation&#44; laser ablation&#44; and airway stents&#41;&#44; surgical intervention&#44; or a combination of these methods&#44; no treatment consensus or guidelines have been established for this condition&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2&#44;3</span></a> The management of delayed tracheobronchial stenosis caused by blunt chest trauma highly depends on patient status&#44; severity of symptoms&#44; location and extent of stenosis&#44; degree of distal pulmonary parenchymal destruction&#44; and local expertise&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Here&#44; we describe the case of a patient with delayed right main bronchus stenosis involving the tracheal carina after blunt chest trauma who was successfully treated with tracheobronchial anastomosis&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 34-year old male current smoker had been involved in a motor vehicle accident at the age of 21&#46; He suffered bilateral pneumothorax&#44; which was treated only with chest drainage tubes&#46; The patient developed pneumonia every 12 years starting at the age of 24&#46; During the pneumonia episodes&#44; he complained of wheezing and dyspnea&#46; The patient did not have any lower respiratory tract infections during childhood&#46; Recently&#44; he started having recurrent obstructive pneumonia every 12 months&#44; which led him to visit the Department of Respiratory Medicine of the local hospital&#46; Chest computed tomography &#40;CT&#41; showed ground grass opacity and consolidation in the right middle and lower lobes&#44; and bronchial mucous retention with stenosis of the right main bronchus&#44; the length of which was less than 1<span class="elsevierStyleHsp" style=""></span>cm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#44; B&#41;&#46; Flexible fiber-optic bronchoscopy &#40;FOB&#41; showed a fibrotic lesion causing almost complete stenosis of the proximal right main bronchus&#44; with the exception of a pinhole located at the lateral posterior aspect of the stenosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; His forced vital capacity &#40;FVC&#41;&#44; forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s &#40;FEV<span class="elsevierStyleInf">1</span>&#41;&#44; FEV<span class="elsevierStyleInf">1</span>&#47;FVC ratio&#44; expiratory reserve volume &#40;ERV&#41;&#44; and residual volume &#40;RV&#41;&#47;total lung capacity &#40;TLC&#41; ratio&#44; were 92&#46;4&#37; &#40;4&#46;23<span class="elsevierStyleHsp" style=""></span>L&#41;&#44; 61&#46;4&#37; &#40;2&#46;47<span class="elsevierStyleHsp" style=""></span>L&#41;&#44; 58&#46;39&#37;&#44; 76&#46;8&#37; &#40;1&#46;29<span class="elsevierStyleHsp" style=""></span>L&#41;&#44; and 32&#46;13&#37;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>F&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was referred to our hospital for treatment of the right main bronchus stenosis&#46; We selected surgical intervention &#40;supplemental video&#41;&#46; Under general single-lung ventilation with a double-lumen tube&#44; we performed a right posterolateral thoracotomy and found that the lung had adhered to the chest wall and that the middle and lower lobes showed consolidation&#46; We opened the right main bronchus at the proximal side&#59; however&#44; the stenosis remained&#44; and we resected half of the tracheal carina and the lower part of the trachea&#46; At the distal side&#44; the main bronchus was removed to the smallest extent possible&#44; which was approximately 2<span class="elsevierStyleHsp" style=""></span>cm&#46; Anastomosis was performed with continuous suture for the mediastinal side and interrupted suture for the other part using 4-0 polydioxanone suture&#44; and pedicled pericardial fat tissue was used as a cover&#46; The patient was discharged on postoperative day 12 without any postoperative complications&#46; Pathological analysis of the resected specimen showed the presence of granulation tissue with a focal fibrosis lesion and no evidence of malignancy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Follow-up chest CT &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41; and flexible FOB &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E&#41; performed 3 months postoperatively showed successful healing of the anastomosis with luminal patency&#46; A follow-up pulmonary function test revealed improvement of the obstructive ventilatory defect based on FVC&#44; FEV<span class="elsevierStyleInf">1</span>&#44; FEV<span class="elsevierStyleInf">1</span>&#47;FVC ratio&#44; ERV&#44; and RV&#47;TLC ratio values of 101&#46;3&#37; &#40;4&#46;66<span class="elsevierStyleHsp" style=""></span>L&#41;&#44; 93&#46;3&#37; &#40;3&#46;77<span class="elsevierStyleHsp" style=""></span>L&#41;&#44; 80&#46;9&#37;&#44; 98&#46;8&#37; &#40;1&#46;67<span class="elsevierStyleHsp" style=""></span>L&#41;&#44; and 27&#46;6&#37;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>G&#41;&#46; The patient did not develop pneumonia for 10 months after the operation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">If stenosis involves the tracheal carina&#44; surgical intervention may be associated with an increased risk because of technical difficulties and a high level of postoperative complications&#44; such as anastomotic dehiscence and restenosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4&#44;5</span></a> Two previous studies showed that delayed airway stenosis with involvement of the tracheal carina after blunt chest trauma was successfully treated with repeated balloon dilation and stent placement&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6&#44;7</span></a> Thus&#44; it was considered that we should perform a bronchoscopic intervention&#59; however&#44; we decided on surgical intervention for the following reasons&#46; First&#44; we considered that we could perform tension-free anastomosis&#44; because the stenotic lesion affected the main bronchus exclusively&#46; Second&#44; the stenosis did not induce the formation of a right lung abscess&#46; Third&#44; bronchoscopic treatments might require repeated interventions because of migration and formation of granulation and because of the recurrence of stenosis after stent removal&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Forth&#44; the patient was young and his preoperative condition was good&#46; In the present case&#44; surgical intervention was an acceptable method for managing stenosis involving the carina&#46; Previous studies reported no perioperative mortality by surgical intervention for benign airway stenosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">9&#44;10</span></a> Therefore&#44; surgical intervention should be considered in the future under the same condition&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The median time from initial injury to diagnosis of delayed tracheobronchial stenosis is 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Kiser et al&#46; reported an absence of association between time to the diagnosis of delayed tracheobronchial stenosis and the rate of successful surgical repair&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> Perioperative complications related to surgical intervention for tracheobronchial stenosis includes empyema&#44; rebleeding&#44; stenosis&#44; and fistula&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2&#44;12</span></a> The current patient was diagnosed 13 years after the initial motor vehicle accident and experienced no perioperative complications&#46; The long-term complications or long-term follow-up outcomes are unknown<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a>&#59; therefore&#44; we should carefully investigate the future disease profiles of this case&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Here&#44; we successfully treated a case of delayed airway stenosis involving the tracheal carina with surgical intervention&#46; As the treatment consensus or guidelines for delayed airway stenosis after blunt chest trauma have not been established&#44; a very careful clinical and radiological evaluation is needed to prevent peri- and post-operative complications before deciding on whether to adapt this technique&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial conflicts</span><p id="par0040" class="elsevierStylePara elsevierViewall">This study was funded in part by the JSPS KAKENHI 19K17634 &#40;SH&#41;&#46; The Department of Advanced Medicine for Respiratory Failure is a Department of Collaborative Research Laboratory funded by Teijin Pharma&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">Satoshi Hamada reports grants from Teijin Pharma&#44; outside the submitted work&#46;</p></span></span>"
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